The Troublesome Ethics of Entrepreneurship in Medical School Admissions

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Medical school applications are becoming big business, and a rather troubling expression of supply and demand economics.

The “demand” side consists of the many thousands of young people in North America engaged in the highly competitive process of applying to the limited number of seats available at publicly subsidized Canadian and American schools. Rebecca Jozsa, our intrepid Admissions Officer and I recently explored the “supply” side by carrying out a simple Google search of options available to the assist the aspiring medical school applicant.

For MCAT preparation, we found no fewer than 22 available courses (probably an underestimate). The “MCAT Ultimate LiveOnline 123-hour” experience is offered multiple times per year for $2,199US. For those who prefer more intense and more personal preparations, the “MCAT Summer Immersion” experience can be had for $9,499US, not counting, of course transportation and accommodation. The “Most Comprehensive Prep Course in Canada” runs over 10 weeks, costs $2,195, comes with testimonials from satisfied customers and features both instruction by successful students and “unlimited free repeat policy”. There are many other choices, a veritable smorgasbord of choices.

One can also opt for more comprehensive guidance through the entire application process. One group provides the following offering: “With our flagship service, we offer unparalleled quality that will make your application to medical school stand out”. In addition to “MCAT prep”, clients can opt for any or all of “Online Diagnostic”, “Comprehensive Application Planning”, “Application Review”, “CASPer prep”, “Interview Crash Course”, “Interview Preparation”, and “MMI prep”. Costs, understandably, vary based on individual preference and perceived need, but appear to range from a few hundred dollars for individual components to more comprehensive packages such as the Platinum bundle which goes for $3500US. It’s hard to get all the details as to what’s available without engaging one of the friendly “consultants” for a “personalized needs analysis” (which we declined) but the sky appears to be the limit in terms of costs. Some arrangements even come with money-back guarantees!

It’s clear from the advertising that many of these programs employ, or are even operated by, medical students or recent grads. Who, after all, would be in a better position to provide the “inside information” so essential to success?

So, is all this a problem?

On the one hand, all this is perfectly legal free enterprise. It’s addressing a perceived need, clients are fully informed and fully competent, no one is forced to engage these processes unwillingly. It could be argued that these programs allow very worthy and genuinely motivated young people to pursue their dreams and overcome many of the unintentional barriers that we all would acknowledge are inherent in the admissions system. One could argue that medical schools themselves have given rise to these business opportunities by making the MCAT such an integral component of the admission process, while at the same time dropping basic science prerequisites.

On the other hand, one must also acknowledge a number of potential concerns:

  • The widespread availability of these services may force students to participate to simply not be disadvantaged relative to other applicants. It’s no understatement to say that candidates feel desperate for any advantage in the process. That desperation, it could be argued, is being exploited.
  • This intensive preparation and rehearsing for the various application processes may result in candidates portraying themselves in an unrealistic fashion, thus subverting a process fundamentally intended to ensure applicants are appropriately suited to a career in medicine. Such “mismatches” can be disservice to all, including the applicant themselves.
  • These services are obviously expensive, adding a further socioeconomic barrier to medical education, a problem widely acknowledged in both Canada and the United States.
  • The involvement of medical students, as paid consultants or instructors is troubling. Their recent experience with the details of application processes, including the structured interviews (for which most schools require them to sign a non-disclosure agreement) makes them attractive for this role, but also sets up an ethical dilemma: Can they undertake to help applicants navigate their interviews without sharing information or insights they have acquired as a result of their own experience? Even if specifics are not explicitly divulged, it’s hard to imagine that their recent intimate involvement in the process won’t find its way into their “counseling”.

All this provides lessons and demands reflection on a number of levels.

For the aspiring applicant, perhaps a word of caution. The principle of “caveat emptor” (let the buyer beware) very much applies. There is no accreditation or credentialing process for these offerings. Applicants may not be getting valid advice. I’ve heard anecdotally from students who have been advised to avoid expressing any personal opinions and instead memorize and regurgitate the prepared responses to anticipated questions. Admission committees and interviewers, searching for sincerity and deep commitment to a career in medicine, are astute assessors and have become very attuned to the “coached” candidate. They will become even more vigilant. The sincerity and true commitment they’re looking for tends to stand out, and is very difficult to artificially manufacture.

This entrepreneurial phenomenon should also cause medical admissions committees to reflect on their processes. One has to question the validity of the MCAT as an assessment of scientific aptitude if an “immersion experience” is truly effective in influencing test results. Do we believe a background or interest in basic science is an important applicant characteristic? If so, do we feel successfully undertaking an MCAT prep course meets that criterion?

For medical students, entering a profession that is self-regulatory and rightfully expects high levels of personal integrity and accountability, opportunities to become involved in these programs pose perhaps their first personal ethical dilemma. Clearly, what makes them attractive to these agencies is not their personal counseling or teaching skills, but rather their status as successful medical school applicants, which brings considerable cachet and intimate knowledge which is of high value. They will find (as they will as practicing physicians) that their professional identity can’t be easily separated from their personal lives, and therefore puts them in an ethically ambiguous position.

In our society, it seems supply will always be found when demand exists and sufficient resources are made available. That this has extended to the medical school admission process should come as no surprise. However, it does raise some unintended, but nonetheless concerning consequences. As always, your views on this issue are most welcome.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

 

17 Responses to The Troublesome Ethics of Entrepreneurship in Medical School Admissions

  1. ps reddy says:

    We are to blame for this mess. To believe only socially competent people can be allowed to become doctors takes away an opportunity for an Einstein whose ethics and problem solving skills are not expressed well like those who can express it to put a show. It is more like a drama than a test. A more objective evaluation of ability is required without the examiners who are biased to make a better selection process

    • Certainly candidates vary in their ability to portray themselves in an interview and try very hard to anticipate what panels may be looking for. However, you might be underestimating the ability of experienced interviewers to see through these performances. Sincerity is hard to fake.

  2. David Walker says:

    Well expressed Tony. And the law of unintended consequences applies here as well. Over my years as dean, i recall a number students who availed themselves of these services, especially the personal coaching aspects to assist with the interview process. In these admittedly anecdotal experiences the true expression of individuality was suppressed with negative results. After advice and in subsequent applications some of these individuals were successful. They recognized that they had not been helped.

  3. S says:

    This is a problem that will forever plague the culture of medical school admissions. “Premed” programs churn out thousands of graduates a year of which (maybe?) 10% will enter the promised land. The remainder live in purgatory. You’re absolutely right, this hellish limbo crafts a desperation: a dread that has been exploited for financial gain. Whether it is the for-profit schools in the Caribbean/Europe/Narnia or the myriad of consulting services offering CASPER sim tests, MCAT-prep-adamantium-packages, essay “editing” services, ABS “guidance”, sending admissions committee members girl scout cookies… something is rotten in the state of premed. Every time a step is taken to create a more “holistic” review process, a service is offered to give any applicant willing to pay applicant the inside lane.

    The socioeconomic barrier dilemma is certainly troubling, as someone who grew up in (relative) poverty, there exists a sense of mistrust of physicians (and politicians, the wealthy etc.) in poorer communities like mine, (in my mind) because of a perceived inability to empathize with hardship or similarly, a perceived aura of nepotism that surrounds those who have climbed the ivory tower. What’s the solution? Points for socioeconomically disadvantaged candidates? A newfangled test for ability to empathize (with proven reliability, validity, peer-reviewed, meta-analysis-shiny-stamped-approved etc.)? Who knows.

    In the end how do you measure a candidates eagerness, preparedness and aptitude for a profession that they won’t even understand for another half decade, all in a neat enough package to be reviewed in a timely manner by a team of truly dedicated souls who have probably seen the word “passion” far too many times to count? Heck how do you even reliably measure the “success” of a physician? I’m getting a nagging need to re-watch Gattaca…

    All-in-all I’m just happy to see that admissions committees are aware of the problem. Though I am not envious of their burden of wading through it.

    • Thanks for those comments that so nicely express the challenges. The socioeconomic barrier and issues it raises for servicing of small communities and marginalized populations is certainly real and one we and other schools are attempting to address. Appreciate your insights.

  4. Trevor says:

    It’s reassuring to see healthy skepticism concerning issues around admissions from an Associate Dean at pre-eminent Canadian medical school. The other “supply” side is the limited number of medical seats for a relatively unlimited “demand” of prospective medical students. Given this situation, the question is how are medical schools to decide who are the most worthy candidates? As someone who has been through the admissions process, talked to a number of people, and wondered about the issue, here is some analysis and thoughts towards the issues mentioned in the post as well as the broader admissions context.
    One societal approach reduce the “demand” side of prospective medical students is by using early (younger) admissions, as is done in many European countries, and to a large extent in Québec. The advantage is that the criteria are relatively simpler, and in Québec for instance, admissions are based on grades and an interview. On the other hand, greater understanding and maturity towards the medical profession may occur at a later chronological age, and socio-economic disparities within different secondary school districts may be augmented within the North American context. In an extreme case of admissions experimentation, it seems the Dutch had a partial lottery system of admissions based on grades, then tried a selection system, but finally reverted back towards a partial lottery (1). In the US, since medical education is less tied to provincial regulation, the “supply” side of available seats is increased, but with the disadvantage of an even greater financial burden on the student.
    In the anglophone North American context, reliance on standardized tests like the MCAT seems to present the advantage of relative homogeneity of a test which is loosely tied to the medical curriculum. As such, greater performance on the test may give greater confidence in the ability of a candidate to undertake medical studies. On the other hand, there can be a great time financial and time investement into writing such an test. Moreover, a candidate, who may have promising qualities of a phsyician, but who lacks the requisite background, will clearly be at a disadvantage. Certainly the newest form of the MCAT is not a light undertaking, drawing from an even greater sphere of knowledge.
    Of course the commercialization of MCAT preparation, sometimes to extreme levels as mentioned in the post leads to the charge that success on the MCAT is more due to resources rather than aptitude. Moreover, a number of students work during the summer, and the syllabi on the MCAT may not be closely tied to their university studies, leaving them at a greater disadvantage. While on the surface pre-requisite courses appear to avoid these difficulties, there are also costs associated with taking courses solely for the purpose of entering medical school. The costs are not only financial and time, but there is also an opportunity cost for not pursuing other studies, especially with regards to unsuccesful applicants.
    Although on the surface, greater reliance then on GPA appears to circumvent these problems, much of the same criticism can be leveled at GPA as a sole measure of aptitude. Greater resources can permit personalized tutoring, more time during the scholastic year and summer to focus on studies, and perhaps more fundamentally the realization of the importance and strategies towards scholastic achievement, whether it be program or university selection. A quick glance on the University of Toronto’s admissions website indicates a relatively large increase in average admissions GPA from about 3.8 fifteen years ago to almost 4.0 today. Is this a reflection of great academic aptitude or greater awareness and strategies towards the importance of maintaining and increasing GPA? Or even the product of “grade inflation”?
    Clearly the task of admissions is not easy, and it shouldn’t be surprising of the great variety of approaches within even the Canadian context. While formulaic criteria have the advantage of transparency, over-reliance on sole criteria like MCAT or GPA can lead to distortions. It is evident that although a more holistic approach is desirable, it easy to level criticisms of bias or favoritism, not to mention possible inconsitencies in evaluation of candidates on top the additional time and effort involved. Another component mentioned in the post – the “inside information” for interview preparation may provide an unfair advantage only available to some, not to mention the ethics involved in the entrepreneurial aspects.
    Unfortunately, there doesn’t seem to be a great deal of reliable information concerning the efficacy of such preparation for the MCAT or otherwise. It doesn’t appear as if would be in the interest of the test preparation companies to provide and release that information either. However, the AAMC does collect data on test takers, including test preparation, and as such it should be possible to obtain at least a rudimentary sense of the effectiveness of such preparation, were it to be ethically permissible. A similar anonymous questionnaire could possible be implemented during medical interviews, although this also may be a delicate issue. Ultimately, the availability of greater resources will always permit an advantage, the question is the relative magnitude of the advantage.

    (1) (http://student.bmj.com/student/view-article.html?id=sbmj0305138a).

  5. Tommy says:

    Very well put Dr. Sanfilippo, I am very happy to see that you have brought light to the hoops that many students think they have to jump through to make it into medical school.

    Being an undergraduate student, I can definitely acknowledge the absurdities in many of the medical school admissions preparatory courses offered in North America. One thing I would mention is the time commitment needed for these preparatory courses, especially those for the MCAT. Many of my peers take a fraction if not the whole of their summer to study for the exam, spending $2000+ enrolling in an intensive course. This means that those same students are left with very little time to work during the summer to make the money they may require to offset costs of university or the preparatory course itself. The repercussions of this system is typically most evident among students coming from lower income backgrounds. As a result, many students do not access these courses and are left to manage their summer job, on top of studying for an MCAT with very little guidance. The other option is students study for their MCAT during the school year. It is quite unrealistic to expect a student to maintain a high academic standing, their commitments to community service, and potentially work a part time job to offset the costs of tuition and rent, all whilst studying for an extremely intensive exam. This is something I can attest to having just written my MCAT, with my studying restricted to the school year.

    The system that is established in this situation perpetuates unequal opportunities among socioeconomic groups. Although I do acknowledge the feasibility of people coming from a relatively disadvantaged background entering medicine, there is an evident advantage in meeting the “application criteria” for those who come from wealthier backgrounds. I would also go into a more intersectional analysis discussing the roles of other social identities including sex, race, gender, and nationality in the medical school system, but that would turn this reply into a dissertation.

    With that being said, this is a pattern that is common with many other graduate and even undergraduate programs. With the socialist and Hippocratic principles at the basis of the best medical systems across the globe, I would only hope that those same principles will be reflected in a novel system that provides an equal opportunity to anyone hoping to study medicine, regardless of their social identity (and not only on face value). If we are going to push towards a meritocracy, the medical system will be a great place to start!

    • Thanks Tommy. I think you make some very valid points. I particularly appreciate you providing the student perspective on the issue of socieoeconomic disparities in the application process. Be happy to hear more of your thoughts for studying the issue.

    • S says:

      I’m with you here Tommy. In my case I studied while working full-time in the summer as a research assistant (which meant sometimes taking my work home with me). I was “forced” down this road because paying for school myself was the only option that wouldn’t financially inconvenience (read: bankrupt) my mother/siblings. Up at 6:30 am, home at 5 pm, eat and nap till 7 pm, study until 1 or 2 am, rinse, lather, repeat (did I mention this was summer? and that my place had no AC?). My friends, who had the means to, made use of expensive prep courses, TPR/Kaplan/ExamKrackers books, AAMC test access etc., I bought some 5 year old books second hand and lots of coffee.

      It goes beyond this too. Volunteering is a major component of the process, and justly so, schools are looking for candidates that have demonstrated a keen understanding of altruism, advocacy and community service. While most of my peers packed on volunteering in their summers, I worked 2 even occasionally 3 jobs to scrape together money for tuition. Though I made some of this up during the school year, my service hours pale in comparison to those who had the means to dedicate this time freely over their holidays. And though this employment is reflected in my application, I have lingering doubts that the factory or labour work I committed to carries the same weight…

      I wish that socioeconomically disadvantaged applicants like you and I had a chance to voice these barriers in our applications (the US system does a great job at this!). I mean isn’t a core value of educating a generation of physicians an assurance that (as a group) their life experiences, culture, backgrounds etc. reflect the population they serve? There’s plenty of literature highlighting the disparity in the income breakdown of matriculants vs the Canadian population. I understand the need for an objective admissions process. But we’re ignoring a massive vertical inequity in access to the experiences/tools/materials to be a classically “strong” candidate within the applicant pool.

      This isn’t a problem exclusive to medical school admissions, I just wish that a better job was being done in identifying and ameliorating the issues.

  6. Cai says:

    Very well said everyone. I would like to provide my two cents on the main topic of ethics in entrepreneurship in medical school admissions.

    As an applicant from a remote community (Yellowknife), I have been advised by multiple local physicians that I “should try those preparation services” after they know I am applying to medicine. It is the only financially feasible way for premeds who live in remote areas to compete with city applicants, they say. The reasons are:

    1. It costs 400+CAD to fly to nearest city (Edmonton) to take MCAT and come back, in unfortunate cases applicants need to fly to Vancouver or Saskatoon for MCAT seats. Plus the test fee, accommodation, meals and opportunity cost (take days off work), we are talking about more than a grand. Two tests will cost as much as the major prep course in the market. How many tests do medicine applicants usually take? The average I have heard is 2-3 times, in some extreme cases it will be 4 or 5. The simple math is, if a prep course can save us two trips, it is worth the money.

    2. It is arguable what are the best ways to improve MMI performance, but appropriate amount of practicing will definitely be one of them. All major cities in Canada have MMI prep groups, where students run MMI mock ups to familiarize with the format, and to practice all types of questions. The only option for remote applicants is “Skype interview”, which in my mind is no where close to the intensity of real MMI. Comparing with a ticket to other city for interview preparation, a mock up session which usually costs around 250CAD sounds much more reasonable.

    To sum up, in order to achieve same score, it costs way more for remote applicants. From social equity perspective, is fair access provided to all applicants?

    So what I am really talking about here in this response, is not only the ethical dilemma of costly services in medical schools admissions, but also how medical schools have set barriers(unintentionally) to remote applicants (a group that most likely will go back and serve remote communities) while pursuing objectivity.

    Schools like Queen’s and Western, using an very efficient approach to set up MCAT cutoff to screen out a large portion of applicants (I appreicate how difficult it is to review 4000+ applications!), are actually pushing away applicants like myself. (Queen’s is my dream school 🙂
    I knew from the very beginning that MCAT is my biggest weakness in getting an interview from Queen’s, but I just couldn’t afford another trip to Vancouver last summer. And I know that I am not alone.

    Thanks for reading and apologies for typos and abbreviations.

  7. Kanji Nakatsu says:

    Tony:

    Thanks for raising this in our consciences; I knew that there was some entrepreneurship with respect to the MCATs but the extra “offerings” are new to me. The cost and thus the disincentive for poorer families has to be a concern. As these offerings are legal there seems to be little that we can do about there presence and influence. The only thing that I could suggest is the inclusion of a question in the interviews along the lines of “What extracurricular preparation have you done for your application to medical school?” This might even help those that have received “bad” advice as you have mentioned above.

    Many thanks for your continuing efforts on behalf of all of us,
    Kanji

  8. Stephen Zimmer says:

    It’s pretty difficult to determine who will be the better candidates, much less the best physicians. I remember my first lecture at queen’s. I forget the teacher’s name, but I remember distiinctkly him saying something to the effect of “Congratulations, all that sucking up and volunteering as camp counsellors you did has paid off”

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